2.0 Analysis 2.1 Meteorological Conditions and AWOS Station At the time of the accident, the AWOS station transmitted the data corresponding to the current meteorological conditions at Havre-Saint-Pierre. However, those data were not retransmitted to the pilot via the specialist at the Sept-les FSS. A glitch in the CODCON central computer at Dorval caused a delay of about three hours--from 1414 to 1735--in the transmission of the data for Havre-Saint-Pierre; the accident occurred during that period. 2.2 Pilot Preparation The pilot commenced his descent about 25 nm from Havre-Saint-Pierre. He requested the latest meteorological sequence from the Sept-les FSS specialist. The sequence was sent to him, and it indicated VMC. The pilot used an altimeter setting that was over 90 minutes old, thereby introducing an error of about 20 feet into the altimeter. However, this error is negligible and is not considered a factor in the accident. After seeing the lights of the town, the pilot, relying on the weather report he had received, proceeded with the instrument approach to runway 27. The pilot expected to encounter VMC during the approach, and he did not prepare for the possibility that he might have to execute a missed approach. As it was dark, the pilot could not see the clouds and snow showers around the airport. During the instrument approach, the pilot did not notice that the IMC encountered were very different from the VMC he was expecting. The IMC encountered did not enable him to establish the required visual references during the approach. 2.3 Workload and Pilot Attention The pilot's workload was increased because he had to fly an instrument approach as the sole occupant on board, in the dark, in moderate turbulence, and without having established the visual references he expected. His workload was further increased by the radio calls he made during the final approach to request the weather at the airport. During the approach the pilot had to scan the instruments, try to establish the required visual references, and use the radio. As the pilot had to concentrate on all these tasks during the approach, the instruments, particularly the altimeter, were scanned less attentively. As he was no longer monitoring his vertical navigation effectively, the pilot allowed the aircraft to descend below the MDA until it struck the ground. Aviation regulations and the Canada Air Pilot specify that the pilot was not authorized to descend below 1,600 feet asl unless he established and maintained the required visual references with the runway or runway markings. Not having established the required visual references, the pilot continued the approach in IMC until the aircraft struck the ground, although he could have executed a missed approach. Executing a missed approach would have allowed the pilot either to make another instrument approach in known IMC, or to proceed to the alternate airport if the conditions precluded him from landing at Havre-Saint-Pierre Airport. 3.0 Conclusions 3.1 Findings The pilot was qualified for the flight. The Havre-Saint-Pierre AWOS station transmitted the meteorological data that had been captured. The Environment Canada CODCON computer at Dorval was unable to process or transmit data to users for a period of three hours, and the flight and accident occurred during that period. The pilot was not prepared to execute an instrument approach in IMC. The pilot was not prepared to execute a missed approach at a predetermined altitude in the event that he could not establish visual contact with the runway or its surroundings. The pilot continued the descent below the MDA without having established and maintained the required visual references with the runway or runway markings. On the final approach, the aircraft struck some trees and crashed on the extended centre line of runway 27, approximately 1.5 miles short of the runway threshold. 3.2 Causes The pilot continued the descent below the MDA without the required visual references. 4.0 Safety Action 4.1 Action Taken 4.1.1 Automated Weather Observation Systems Since the occurrence, Transport Canada has issued a class 1 Notice to Airmen (NOTAM) and has sent an Aviation Notice concerning deficiencies of the AWOS to all licensed pilots in Canada. Further, Transport Canada, in partnership with Environment Canada, has created a task force to rectify the deficiencies and validate improved AWOS performance. In the meantime, there is a temporary hold on the commissioning of future AWOS sites, and some existing sites are being manned by observers.